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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

Patient Access Network Foundation (PAN) Application: Contact program

 

Brand Name Medications Covered

 
  • 8-MOP
  • Levoxyl
  • A-Hydrocort
  • Levulan
  • A-Methapred
  • Lexiva
  • Abraxane
  • Lialda
  • Absorica
  • Lioresal
  • Accolate
  • Lipitor
  • Accuneb
  • Lipodox
  • Accupril
  • Lipofen
  • Accuretic
  • Liptruzet
  • Aceon
  • Livalo
  • Actemra
  • Locoid
  • Acthrel
  • Locoid Lipocream
  • Actimmune
  • Lodine
  • Actonel
  • Lodosyn
  • Adalat CC
  • Lofibra
  • Adcetris
  • Lonsurf
  • Adcirca
  • Lopid
  • Adempas
  • Lopressor
  • Adriamycin
  • Lopressor HCT
  • Adrucil
  • Lotensin
  • Advair Diskus
  • Lotensin HCT
  • Advair HFA
  • Lovaza
  • Advate
  • Lucentis
  • Advicor
  • Lufyllin
  • Adynovate
  • Lupron Depot
  • Aerospan
  • Luxiq
  • Afeditab CR
  • Luxturna
  • Afinitor
  • Lynparza
  • Afstyla
  • Lysodren
  • Agrylin
  • Lysteda
  • AirDuo RespiClick
  • Macugen
  • Akynzeo
  • Marinol
  • ALA-Cort
  • Marqibo
  • ALA-Scalp
  • MatriStem Burn Matrix
  • Aldactazide
  • MatriStem MicroMatrix
  • Aldactone
  • Matulane
  • Aldara
  • Matzim
  • Alecensa
  • Mavik
  • Aleve
  • Mavyret
  • Alimta
  • Maxidex
  • Aliqopa
  • Maxitrol
  • Alkeran
  • Maxzide
  • AlloDerm
  • Megace
  • AlloSkin
  • Megace ES
  • AlloWrap
  • Mekinist
  • Alora
  • Menest
  • Alphanate
  • Menostar
  • AlphaNine SD
  • Mephyton
  • Alprolix
  • Mesnex
  • Altace
  • Metastron
  • Altoprev
  • Metopirone
  • Alunbrig
  • Metozolv tablet; orally disintegrating
  • Alvesco
  • Mevacor
  • Amicar
  • Miacalcin
  • Amidate
  • Micardis
  • AmLactin
  • MiCort HC
  • Amnesteem
  • Microzide
  • Ampyra
  • Mifeprex
  • Anaprox DS
  • Millipred
  • Androxy
  • Minivelle
  • Antara
  • Mirapex ER
  • Anzemet
  • Mobic
  • ApexiCon E
  • Moderiba
  • Apligraf
  • Monoclate-P vial; single-use
  • Apokyn
  • Mononine
  • Apriso
  • Mozobil
  • Aptivus
  • Multaq
  • AquaDeks
  • Mustargen
  • AquaSol A
  • Myleran
  • AquaSol E
  • Mylotarg
  • Aranesp
  • Myorisan
  • Arava
  • Nalfon
  • Arimidex
  • Naprelan
  • Armonair Respiclick
  • Naprosyn
  • Arnuity Ellipta
  • Navelbine
  • Aromasin
  • Neo-Polycin
  • Arranon
  • Neo-Synalar
  • ArthroFlex
  • Neoral
  • Arthrotec
  • Neosporin
  • Arzerra
  • Nerlynx
  • Asacol HD
  • Neulasta
  • Asmanex
  • Neupogen
  • Astagraf XL
  • Neupro
  • Atabex
  • Nexavar
  • Atacand
  • Nexterone
  • Atacand HCT
  • Niacor
  • Atelvia
  • Niaspan
  • Atgam
  • Nilandron
  • Ativan
  • Ninlaro
  • Atripla
  • Nipent
  • Atrovent HFA
  • Niravam
  • Aubagio
  • Norpace CR
  • Auryxia
  • Norvasc
  • Avalide
  • Norvir
  • Avapro
  • Novoeight
  • Avastin
  • NovoSeven RT
  • Avonex
  • Nplate
  • Azasan
  • Nucala
  • Azilect
  • Nucort
  • Azulfidine
  • Nuplazid
  • Bavencio
  • Nutrestore
  • BCG Vaccine
  • Nuwiq
  • Bebulin
  • Oasis
  • Beleodaq
  • Obizur
  • Benadryl
  • Ocrevus
  • Bendeka
  • Octagam
  • Benefix
  • Ocuvite Lutien
  • Benicar
  • Odefsey
  • Benicar HCT
  • Odomzo
  • Benlysta
  • Ofev
  • Besponsa
  • Olux
  • BETA HC
  • Olysio
  • Betapace
  • Omnipred
  • Betaseron
  • Oncaspar
  • Bicnu
  • Onivyde
  • BiDil
  • Opdivo
  • Biktarvy
  • Opsumit
  • Binosto
  • Orapred
  • BioDFence
  • Orencia
  • BioVance
  • Orenitram
  • Bivigam
  • Otezla
  • Bleo 15K
  • Otrexup
  • Blincyto
  • Oxsoralen
  • Boniva
  • Ozurdex
  • Bosulif
  • Pacerone
  • Breo Ellipta
  • Pamidronate Disodium injection
  • Brevibloc
  • Pancreaze
  • Busulfex
  • Pandel
  • Bystolic
  • Parcopa
  • Cabometyx
  • Parlodel
  • Caduet
  • Pediaderm HC
  • Calan SR
  • Pediaderm TA
  • Calcidol
  • Pediapred
  • Calcitrene
  • Pegasys
  • Calphron
  • Pennsaid
  • Calquence
  • Pentasa
  • Cambia
  • Perforomist
  • Campath
  • Perjeta
  • Camptosar
  • Pertzye
  • Canasa
  • Phenergan
  • Capex
  • Phoslo
  • Caprelsa
  • Phoslyra
  • Carac
  • Photofrin
  • Cardizem LA
  • Plaquenil
  • Carimune NF
  • Plegridy
  • Carospir
  • Pomalyst
  • Cartia XT
  • Portrazza
  • Casodex
  • Praluent
  • Cataflam
  • Pravachol
  • CeeNU
  • Pred Forte
  • Celebrex
  • Pred Mild
  • Celestone
  • Pred-G
  • Cellcept
  • Prelone
  • Cenestin
  • Premarin
  • Cerdelga
  • Prevalite
  • Cerezyme
  • Prezcobix
  • Cerubidine
  • Prezista
  • Cesamet
  • PriMatrix
  • Chemet
  • Prinivil
  • Cimduo
  • Privigen
  • Cimzia
  • Proair HFA
  • Cinqair
  • Proair Respiclick
  • Cinvanti
  • Procardia XL
  • Claravis
  • Procrit
  • ClarixFlo
  • Profilnine
  • Climara
  • Proglycem
  • Clobex
  • Prograf
  • Clodan
  • Proleukin
  • Cloderm
  • Prolia
  • Clolar
  • Promacta
  • Cogentin
  • Promethegan
  • Colazal
  • Promogran
  • Colestid
  • Protopic
  • Combivent Respimat
  • Provenge
  • Combivir
  • Proventil HFA
  • Cometriq
  • Psorcon
  • Compazine
  • Pulmicort
  • Complera
  • PuraPly
  • Compro
  • Purinethol
  • Comtan
  • Purixan
  • Copaxone
  • Qbrelis
  • Copegus
  • Quadramet
  • Cordarone
  • Quenalin
  • Cordran
  • Questran
  • Coreg CR
  • QVAR
  • Corgard
  • QVAR RediHaler
  • Corlanor
  • Rapamune
  • Cormax
  • Rasuvo
  • Cortaid
  • Rayaldee
  • Cortef
  • Rayos
  • Cortisporin
  • Rebetol
  • Corvert
  • Rebif
  • Corzide
  • Rebinyn
  • Cosentyx
  • Reclast
  • Cotellic
  • Reglan
  • Coumadin
  • Regranex
  • Cozaar
  • Remicade
  • Creon
  • Remodulin
  • Crestor
  • Renagel
  • Crixivan
  • Renflexis
  • Cuprimine
  • Renvela
  • Cutivate
  • Repatha Sureclick auto-injector; pre-filled
  • Cyclogyl
  • Replesta
  • Cyklokapron
  • Requip
  • Cymetra
  • Rescriptor
  • Cyramza
  • Restasis Multidose
  • Dacogen
  • Retisert
  • Daklinza
  • Retrovir
  • Darzalex
  • Revatio
  • Daunoxome
  • Revlimid
  • Daypro
  • Reyataz
  • DDAVP
  • Rheumatrex
  • Delestrogen
  • Rhophylac
  • Deltasone
  • Ribasphere
  • Delzicol
  • Ribatab
  • Demadex
  • Ridaura
  • Depen
  • Rituxan
  • Depo-Medrol
  • Rituxan Hycela
  • DepoCyt
  • Rixubis
  • Derma-Smoothe
  • Rocaltrol
  • DermaCell
  • Rowasa
  • Dermagraft
  • Rubraca
  • DermaPure
  • Rydapt
  • Dermatop
  • Rytary
  • DermaVest
  • Rythmol
  • DermOtic
  • Sabril
  • Descovy
  • Sancuso
  • Desferal
  • Sandimmune
  • Desonate
  • Sandostatin LAR
  • DesOwen
  • Santyl
  • DexPak
  • Scalacort
  • Digitek
  • Sectral
  • Dilacor XR
  • Selzentry
  • Dilatrate SR
  • Sensipar
  • Dilt-CD
  • Serevent
  • Diltzac
  • Sernivo
  • Diovan
  • Serostim
  • Diovan HCT
  • Sfrowasa
  • Dipentum
  • Signifor
  • Diphen
  • Signifor LAR
  • Diprolene AF
  • Siliq
  • Diuril
  • Silphen
  • Divigel
  • Simcor
  • Docefrez
  • Simponi
  • Doptelet
  • Sinemet
  • Dovonex
  • Singulair
  • Doxil
  • Soltamox
  • Drisdol
  • Somatuline Depot
  • Droxia
  • Somavert
  • Duavee
  • Soriatane
  • Duexis
  • Sorilux
  • Dulera
  • Sorine
  • DuoNeb
  • Sotylize
  • Duopa
  • Sovaldi
  • Dupixent
  • Spiriva
  • Durezol
  • Sprycel
  • Dutoprol
  • Sps
  • Dyazide
  • Stalevo
  • Dyrenium
  • Stelara
  • Edarbi
  • Stimate
  • Edarbyclor
  • Stiolto Respimat
  • Edurant
  • Stivarga
  • Efudex
  • Stribild
  • Eldepryl
  • Sustiva
  • Elelyso
  • Sustol
  • Elestrin
  • Sutent
  • Elidel
  • Sylatron
  • Eligard
  • Symbicort
  • Eliphos
  • Symfi Lo
  • Elixophyllin
  • Synagis
  • Ellence
  • Synalar
  • Elocon
  • Synribo
  • Eloctate
  • Synthroid
  • Eloxatin
  • Syprine
  • Emend
  • Taclonex
  • Empliciti
  • Tafinlar
  • Emtriva
  • Tagrisso
  • Enbrel
  • Taltz
  • Enjuvia
  • Talymed
  • Enstilar
  • Tambocor
  • Entocort EC
  • Tarceva
  • Entresto
  • Targretin
  • Entyvio
  • Tasigna
  • Epaned
  • Tasmar
  • Epclusa
  • Taxotere
  • EpiFix
  • Tazorac
  • Epivir-HBV
  • Taztia
  • Epogen
  • Tecentriq
  • Epzicom
  • Tecfidera
  • Erbitux
  • Technivie
  • Erivedge
  • Temodar
  • Erleada
  • Temovate
  • Erwinaze
  • Temovate E
  • Esbriet
  • Tenoretic
  • Estrace
  • Tenormin
  • Estrasorb
  • Tepadina
  • EstroGel
  • Teveten
  • Etopophos
  • Teveten HCT
  • Eucrisa
  • Texacort
  • Evamist
  • Thalomid
  • Evista
  • Theo-24
  • Evomela
  • Theochron
  • Evotaz
  • TheraCys
  • Excellagen
  • TheraSkin
  • Exelon
  • TherOmega
  • Exjade
  • Thyrogen
  • Extavia
  • Tiazac
  • Eylea
  • TICE BCG
  • EZ Derm
  • Tikosyn
  • Fareston
  • Tirosint
  • Farydak
  • Tivicay
  • Fasenra
  • Tivorbex
  • Faslodex
  • Tobradex
  • Feiba
  • Topicort
  • Feldene
  • Toposar
  • Femara
  • Toprol XL
  • Fenoglide
  • Torisel
  • Fenortho
  • Tracleer
  • Ferriprox
  • Trandate
  • Fibricor
  • Treanda
  • Firmagon
  • Trelstar
  • Flarex
  • Tremfya
  • Flebogamma DIF
  • Trexall
  • Flector
  • Tri-Luma
  • Flo-Pred
  • Trianex
  • Flolan
  • Tricor
  • Flonase
  • Triderm
  • Flovent Diskus
  • Tridesilon
  • Flovent HFA
  • Triesence
  • Fluoroplex
  • Triglide
  • FML
  • Trilipix
  • FML Forte
  • Triumeq
  • Folotyn
  • Trizivir
  • Foradil
  • Trogarzo
  • Fortaderm
  • Truvada
  • Forteo
  • TUMS Products
  • Fortical
  • Tybost
  • Fosamax
  • Tykerb
  • Fosamax Plus D
  • Tymlos
  • Fosrenol
  • Tysabri
  • Fusilev
  • Tyvaso
  • Fuzeon
  • U-Cort
  • Gablofen
  • Uceris
  • Galzin
  • Ultravate
  • GamaSTAN SD
  • Ultresa
  • Gammagard
  • Unite Biomatrix
  • GammaGraft
  • Unithroid
  • Gammaked
  • Univasc
  • Gammaplex
  • Uptravi
  • Gamunex
  • Valchlor
  • Gattex
  • Valstar
  • Gazyva
  • Vanos
  • Gemzar
  • Vantas
  • Gengraf
  • Varubi
  • Genvoya
  • Vaseretic
  • Giazo
  • Vasotec
  • Gilenya
  • Vectibix
  • Gilotrif
  • Vectical
  • Glatopa
  • Velcade
  • Gleevec
  • Veletri
  • Gleostine
  • Velphoro
  • Gliadel
  • Veltassa
  • Gocovri capsule; extended release
  • Venclexta
  • Grafix CORE
  • Ventavis
  • Grafix PRIME
  • Ventolin HFA
  • Graftjacket
  • Verdeso
  • Granisol
  • Verelan
  • Granix
  • Veripred
  • H.P. Acthar
  • Verzenio
  • Halaven
  • Vexol
  • Haldol
  • Vidaza
  • Halog
  • Videx
  • Harvoni
  • Viekira
  • Hecoria
  • Vimovo
  • Hectorol
  • Vincasar PFS
  • Helicoll
  • Viokace
  • Helixate FS vial
  • Viracept
  • Hemangeol
  • Viramune
  • Hemlibra
  • Viread
  • Hemofil-M
  • Vistaril
  • Herceptin
  • Visudyne
  • Hexalen
  • Vitekta
  • Homatropaire
  • Vivelle-Dot
  • Humate-P
  • Voltaren XR
  • Humira
  • Vosevi
  • Hycamtin
  • Vospire ER
  • Hydrea
  • Votrient
  • Hyzaar
  • VPRIV
  • Ibrance
  • Vytorin
  • Iclusig
  • Vyxeos
  • Idamycin PFS
  • Welchol
  • Idelvion
  • Westcort
  • Idhifa
  • Wilate
  • Ifex
  • WinRho SDF
  • Iluvien
  • Xadago
  • Imbruvica
  • Xalkori
  • Imfinzi
  • Xanax
  • Imlygic
  • Xatmep
  • Imuran
  • Xeljanz XR
  • Inderal XR
  • Xeloda
  • Indocin
  • Xerese
  • Infergen
  • Xgeva
  • Inflectra
  • Xifaxan
  • Inlyta
  • Xofigo
  • InnoPran XL
  • Xolair
  • Inspra
  • Xopenex
  • Integra
  • Xtandi
  • Integra Flowable
  • Xyntha
  • Intelence
  • Yervoy
  • Intron A
  • Yescarta
  • Invirase
  • Zaltrap
  • Iressa
  • Zanaflex
  • Isentress
  • Zanosar
  • Isopto Atropine
  • Zaroxolyn
  • Isordil
  • Zarxio
  • Istodax
  • Zavesca
  • Ixempra
  • Zebeta
  • Ixinity
  • Zejula
  • Jadenu
  • Zelapar
  • Jakafi
  • Zelboraf
  • Jantoven
  • Zemplar
  • Jetrea
  • Zenatane
  • Jevtana
  • Zenpep
  • Juluca
  • Zepatier
  • Juxtapid
  • Zerit
  • Kadcyla
  • Zestoretic
  • Kaletra
  • Zestril
  • Kayexalate
  • Zetia
  • Kenalog
  • Zevalin
  • Kevzara
  • Ziac
  • Keytruda
  • Ziagen
  • Kineret
  • Zinbryta
  • Kionex
  • Zipsor
  • Kisqali
  • Zithranol-RR
  • Kisqali Femara tablet; co-pack
  • Zocor
  • Koate DVI injection
  • ZoDex
  • Kogenate FS
  • Zoladex
  • Korlym
  • Zolinza
  • Kovaltry
  • Zometa
  • Kymriah
  • Zonacort
  • Kynamro
  • Zorbtive
  • Kyprolis
  • Zortress
  • Lanoxin
  • Zorvolex
  • Lasix
  • Zuplenz
  • Lemtrada
  • Zydelig
  • Lenvima
  • Zyflo
  • Lescol
  • Zykadia
  • Letairis
  • Zylet
  • Leukeran
  • Zypitamag
  • Leukine
  • Zyprexa Zydis
  • Levo-T
  • Zytiga
 

Generic Name

 
  • abacavir sulfate
  • ibrutinib
  • abacavir sulfate/dolutegravir sodium/lamivudine
  • ibuprofen
  • abacavir sulfate/lamivudine
  • ibuprofen/famotidine
  • abacavir sulfate/lamivudine/zidovudine
  • ibutilide fumarate
  • abaloparatide
  • idarubicin
  • abatacept
  • idelalisib
  • abemaciclib
  • ifosfamide
  • abiraterone acetate
  • ifosfamide/mesna
  • acalabrutinib
  • iloprost
  • acebutolol
  • imatinib
  • acitretin
  • imiglucerase
  • acyclovir hydrocortisone
  • imiquimod
  • adalimumab
  • immune globulin
  • ado-trastuzumab emtansine
  • immune globulin (human)
  • afatinib
  • immune globulin-rhoD Intravenous (human)
  • aflibercept
  • immune globulin; intravenous
  • albuterol
  • immune globulin; intravenous (human)
  • albuterol sulfate
  • immune globulin; iv (human)
  • albuterol sulfate/ipratropium bromide
  • immune globulin; lymphocyte
  • alclometasone dipropionate
  • immune globulin; rh
  • aldesleukin
  • indapamide
  • alectinib
  • indinavir sulfate
  • alemtuzumab
  • indomethacin
  • alendronate sodium
  • infliximab
  • alendronate sodium/cholecalciferol
  • infliximab-ABDA
  • alirocumab
  • infliximab-dyyb
  • alprazolam
  • inotuzumab ozogamicin
  • altretamine
  • interferon alfa-2b
  • aluminum hydroxide
  • interferon alfacon-1
  • amantadine capsule; extended release
  • interferon beta-1a
  • ambrisentan
  • interferon beta-1b
  • amcinonide
  • interferon gamma-1b
  • amiloride
  • ipilimumab
  • amiloride/hydrochlorothiazide
  • ipratropium bromide
  • aminocaproic acid
  • ipratropium bromide/albuterol
  • aminolevulinic acid
  • irbesartan
  • amiodarone
  • irbesartan/hydrochlorothiazide
  • amiotic membrane allograft
  • irinotecan
  • amlodipine besylate
  • irinotecan liposome
  • amlodipine besylate/atorvastatin calcium
  • isosorbide dinitrate
  • ammonium hydroxide lactic acid
  • isosorbide dinitrate/hydralazine
  • amniotic membrane allograft
  • isotretinoin
  • anagrelide
  • ivabradine
  • anakinra
  • ixabepilone
  • anastrozole
  • ixazomib
  • anthralin
  • ixekizumab
  • anti-inhibitor coagulant complex
  • ketoprofen
  • antihemophilic factor (human) injection
  • labetalol
  • antihemophilic factor (human) vial; single-use
  • lamivudine
  • antihemophilic factor (recombinant)
  • lamivudine/tenofovir disoproxil
  • antihemophilic factor (recombinant) pegylated
  • lamivudine/zidovudine
  • antihemophilic factor (recombinant) vial
  • lanreotide acetate
  • antihemophilic factor (recombinant), fc fusion protein
  • lanthanum carbonate
  • antihemophilic factor human
  • lapatinib ditosylate
  • antihemophilic factor recombinant
  • ledipasvir/sofosbuvir
  • antihemophilic factor-von Willebrand factor complex human
  • leflunomide
  • apalutamide
  • lenalidomide
  • apomorphine
  • lenvatinib
  • apremilast
  • letrozole
  • aprepitant
  • leucovorin calcium
  • aqueous vitamin E supplement
  • leuprolide acetate
  • asparaginase erwinia chrysanthemi
  • levalbuterol
  • atazanavir sulfate
  • levalbuterol tartrate
  • atazanavir sulfate/cobicistat
  • levoleucovorin calcium
  • atenolol
  • levothyroxine
  • atenolol/chlorthalidone
  • levothyroxine sodium
  • atezolizumab
  • lisinopril
  • atorvastatin calcium
  • lomitapide
  • atropine sulfate
  • lomustine
  • auranofin
  • lopinavir/ritonavir
  • avatrombopag
  • lorazepam
  • avelumab
  • losartan
  • axicabtagene ciloleucel
  • losartan-hydrochlorothiazide
  • axitinib
  • loteprednol etabonate/tobramycin
  • azacitidine
  • lovastatin
  • azathioprine
  • lovastatin niacin
  • azilsartan kamedoxomil/chlorthalidone
  • macitentan
  • azilsartan medoxomil
  • maraviroc
  • bacitracin zinc/neomycin sulfate/polymyxin b sulfate
  • matrix-wound
  • baclofen
  • matrix; dermal wound
  • balsalazide disodium
  • matrix; human placental tissue
  • bazedoxifene acetate/conjugated estrogens
  • matrix; lyophilized extracellular
  • BCG (live)
  • matrix; regenerative tissue
  • becaplermin
  • matrix; tissue wound
  • beclomethasone dipropionate
  • mechlorethamine
  • belimumab
  • meclofenamate
  • belinostat
  • medical food
  • benazepril
  • megestrol acetate
  • benazepril/hydrochlorothiazide
  • meloxicam
  • bendamustine
  • melphalan
  • benralizumab
  • mepolizumab
  • benztropine
  • mercaptopurine
  • betamethasone
  • mesalamine
  • betamethasone dipropionate
  • mesna
  • betamethasone dipropionate and calcipotriol
  • methotrexate
  • betamethasone valerate
  • methotrexate sodium
  • bevacizumab
  • methoxsalen
  • bexarotene
  • methylprednisolone acetate
  • bicalutamide
  • methylprednisolone sodium succinate
  • bictegravir/emtricitabine/tenofovir alafenamide
  • metoclopramide
  • bilayered skin substitute
  • metoclopramide tablet; orally disintegrating
  • bisoprolol fumarate
  • metolazone
  • bisoprolol fumarate/hydrochlorothiazide
  • metoprolol succinate/hydrochlorothiazide
  • bleomycin
  • metoprolol sussinate
  • blinatumomab
  • metoprolol tartrate
  • bortezomib
  • metoprolol tartrate/hydrochlorothiazide
  • bosentan
  • metyrapone
  • bosutinib monohydrate
  • midostaurin
  • bovine collagen
  • mifepristone
  • brentuximab vedotin
  • miglustat
  • brigatinib
  • mipomersen sodium
  • brodalumab
  • mitomycin
  • bromocriptine
  • mitotane
  • budesonide
  • mitoxantrone
  • budesonide/formoterol fumarate dihydrate
  • moexipril
  • busulfan
  • mometasone
  • cabazitaxel
  • mometasone furoate
  • cabergoline
  • montelukast sodium
  • cabozantinib s-malate
  • multivitamin
  • calcifediol
  • mycophenolate mofetil
  • calcipotriene
  • nabilone
  • calcipotriene hydrate/betamethasone dipropionate
  • nabumetone
  • calcitonin salmon
  • nadolol
  • calcitonin salmon (rDNA origin)
  • nadolol/bendroflumethiazide
  • calcitriol
  • naproxen
  • calcium
  • naproxen sodium
  • calcium acetate
  • naproxen/esomeprazole
  • candesartan cilexetil
  • natalizumab
  • candesartan cilexetil/hydrochlorothiazide
  • nebivolol
  • capecitabine
  • necitumumab
  • captopril
  • nelarabine
  • carbidopa
  • nelfinavir
  • carbidopa/levodopa
  • neomycin sulfate/polymyxin B sulfate
  • carbidopa/levodopa/entacapone
  • neomycin sulfate/polymyxin b sulfate/bacitracin/hydrocortisone acetate
  • carboplatin
  • neratinib maleate
  • carfilzomib
  • netupitant/palonosetron
  • carmustine
  • nevirapine
  • carvedilol
  • niacin
  • celecoxib
  • niacin-simvastatin
  • ceritinib
  • nifedipine
  • certolizumab pegol
  • nilotinib monohydrate
  • cetuximab
  • nilutamide
  • chlorambucil
  • nintedanib esylate
  • chloroquine
  • niraparib
  • chlorothiazide
  • nivolumab
  • chlorthalidone
  • nystatin/triamcinolone acetonide
  • cholestyramine
  • obinutuzumab
  • choline fenofibrate
  • ocrelizumab
  • ciclesonide
  • ocriplasmin
  • cinacalcet
  • octreotide acetate
  • cisplatin
  • ofatumumab
  • cladribine
  • olanzapine
  • clobetasol
  • olaparib
  • clobetasol propionate
  • olmesartan medoxomil
  • clocortolone pivalate
  • olsalazine sodium
  • clofarabine
  • omacetaxine mepesuccinate
  • coagulation factor IX (human)
  • omalizumab
  • coagulation factor IX (recombinant)
  • ombitasvir-paritaprevir-ritonavir
  • coagulation factor IX (recombinant) glycopegylated
  • omega-3 polyunsaturated fatty acid
  • coagulation factor IX (recombinant), albumin fusion protein
  • omega-3-acid ethyl esters
  • coagulation factor IX (recombinant), fc fusion protein
  • ondansentron
  • coagulation factor viia (recombinant)
  • ondansetron
  • cobicistat
  • osimertinib
  • cobimetinib
  • oxaliplatin
  • colesevelam
  • oxaprozin
  • colestipol
  • paclitaxel
  • collagenase
  • palbociclib
  • conjugated estrogens
  • palivizumab
  • conjugated synthetic A estrogens
  • pamidronate injection
  • conjugated synthetic b estrogens
  • pancrelipase
  • copanlisib
  • panitumumab
  • corticoreline ovine triflutate
  • panobinostat lactate
  • corticotropin
  • paricalcitol
  • cortisone acetate
  • pasireotide
  • crisaborole
  • pasireotide diaspartate
  • crizotinib
  • patiromer
  • cromolyn sodium
  • pazopanib
  • cyclopentolate
  • pegaptanib sodium
  • cyclophosphamide
  • pegaspargase
  • cyclosporine
  • pegfilgrastim
  • cyproheptadine
  • peginterferon alfa-2a
  • cytarabine liposome
  • peginterferon alfa-2b
  • dabrafenib
  • peginterferon beta-1a
  • dacarbazine
  • pegvisomant
  • daclatasvir
  • pembrolizumab
  • daclizumab
  • pemetrexed
  • dalfampridine
  • penicillamine
  • danazol
  • pentostatin
  • daratumumab
  • perindopril erbumine
  • darbepoetin alfa
  • pertuzumab
  • darunavir ethanolate
  • phytonadione
  • darunavir ethanolate/cobicistat
  • pimavanserin
  • dasabuvir/ombitasvir/paritaprevir/ritonavir
  • pimecrolimus
  • dasatinib
  • pirfenidone
  • daunorubicin
  • piroxicam
  • daunorubicin/cytarabine
  • pitavastatin
  • decitabine
  • placental membrane allograft
  • deferasirox
  • plerixafor
  • deferiprone
  • pomalidomide
  • deferoxamine
  • ponatinib
  • degarelix acetate
  • porfimer sodium
  • delavirdine
  • pralatrexate
  • denosumab
  • pramipexole dihydrochloride
  • dermal substitute
  • pravastatin sodium
  • desmopressin
  • prednicarbate
  • desmopressin acetate
  • prednisolone
  • desonide
  • prednisolone acetate
  • desoximetasone
  • prednisolone sodium phosphate
  • dexamethasone
  • prednisone
  • dexamethasone/neomycin/polymyxin B
  • prenatal multivitamin
  • diazoxide
  • Procainamide
  • diclofenac
  • procarbazine
  • diclofenac epolamine
  • prochlorperazine
  • diclofenac potassium
  • promethazine
  • diclofenac sodium
  • propafenone
  • diclofenac sodium/misoprostol
  • propranolol
  • didanosine
  • propranolol/hydrochlorothiazide
  • diflorasone
  • quinapril
  • diflorasone diacetate
  • quinidine gluconate
  • diflunisal
  • quinidine sulfate capsule
  • difluprednate
  • radium ra-223 dichloride
  • digoxin
  • raloxifene
  • diltiazem
  • raltegravir
  • dimethyl fumarate
  • ramipril
  • diphenhydramine
  • ramucirumab
  • disopyramide
  • ranibizumab
  • docetaxel
  • rasagiline
  • dofetilide
  • regorafenib
  • dolasetron
  • reslizumab
  • dolutegravir sodium
  • ribavirin
  • dolutegravir/rilpivirine
  • ribociclib
  • doxercalciferol
  • ribociclib-letrozole tablet; co-pack
  • doxorubicin
  • rifaximin
  • doxorubicin liposomal
  • rilpivirine
  • dronabinol
  • rimexolone
  • dronedarone
  • riociguat
  • dupilumab
  • risedronate sodium
  • durvalumab
  • ritonavir
  • dyphylline
  • rituximab
  • efavirenz
  • rituximab/hyaluronidase
  • efavirenz/amivudine/tenofovir disopproxil fumarate
  • rivastigmine
  • efavirenz/emtricitabine/tenofovir disoproxil fumarate
  • rolapitant
  • elbasvir/grazoprevir
  • romidepsin
  • eliglustat tartrate
  • romiplostim
  • elotuzumab
  • ropinirole
  • eltrombopag
  • rosuvastatin calcium
  • elvitegravir
  • rotigotine
  • elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
  • rucaparib
  • elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate
  • ruxolitinib
  • emicizumab
  • sacubitril/valsartan
  • emtricitabine
  • safinamide
  • emtricitabine/rilpivirine/tenofovir alafenamide
  • salicylic acid/sulfur/hydrocortisone
  • emtricitabine/rilpivirine/tenofovir disoproxil fumarate
  • salmeterol xinafoate
  • emtricitabine/tenofovir alafenamide
  • samarium sm-153 lexidronam pentasodium
  • emtricitabine/tenofovir disoproxil fumarate
  • saquinavir
  • enalapril maleate
  • sargramostim
  • enalapril maleate/hydrochlorothiazide
  • sarilumab
  • enalaprilat
  • secukinumab
  • enasidenib
  • selegiline
  • enfuvirtide
  • selexipag
  • entacapone
  • sevelamer
  • enzalutamide
  • sevelamer carbonate
  • epirubicin
  • sildenafil citrate
  • eplerenone
  • simeprevir sodium
  • epoetin alfa
  • simvastatin
  • epoprostenol sodium
  • sipuleucel-T
  • eprosartan
  • sirolimus
  • eprosartan/hydrochlorothiazide
  • sodium polystyrene sulfonate
  • ergocalciferol
  • sofosbuvir
  • eribulin
  • sofosbuvir/velpatasvir
  • erlotinib
  • sofosbuvir/velpatasvir/voxilaprevir
  • esmolol
  • somatropin (rDNA origin)
  • estradiol
  • sonidegib
  • estradiol valerate
  • sorafenib
  • estrogens/esterified
  • sotalol
  • etanercept
  • spironolactone
  • etodolac
  • spironolactone/hydrochlorothiazide
  • etomidate
  • stavudine
  • etoposide
  • streptozocin
  • etravirine
  • strontium chloride SR-89
  • everolimus
  • succimer
  • evolocumab auto-injector; pre-filled
  • sucroferric oxyhydroxide
  • exemestane
  • sulfasalazine
  • ezetimibe
  • sunitinib malate
  • ezetimibe/atorvastatin
  • tacrolimus
  • ezetimibe/simvastatin
  • tadalafil
  • factor IX
  • taliglucerase alfa
  • factor IX complex
  • talimogene laherparepvec
  • factor VIII
  • tamoxifen citrate
  • famotidine/calcium carbonate/magnesium hydroxide
  • tazarotene
  • fenofibrate
  • TBO-filgrastim
  • fenofibric acid
  • teduglutide (rDNA origin)
  • fenoprofen calcium
  • telmisartan
  • ferric citrate
  • temozolomide
  • filgrastim
  • temsirolimus
  • filgrastim-sndz
  • teniposide
  • fingolimod
  • tenofovir disoproxil fumarate
  • flecainide
  • terbutaline sulfate
  • floxuridine
  • teriflunomide
  • fludarabine
  • teriparatide (rDNA origin)
  • flunisolide
  • thalidomide
  • fluocinolone acetonide
  • theophylline
  • fluocinolone acetonide/hydroquinone/tretinoin
  • thiotepa
  • fluocinolone acetonide/neomycin sulfate
  • thyrotropin alfa
  • fluocinolone acetonisde
  • timolol maleate
  • fluocinonide
  • tiotropium bromide
  • fluorometholone
  • tiotropium bromide/olodaterol
  • fluorometholone acetate
  • tipranavir
  • fluorouracil
  • tisagenlecleucel
  • fluoxymesterone
  • tissue; human allograft
  • flurandrenolide
  • tizanidine
  • flurbiprofen
  • tobramycin/dexamethasone
  • flutamide
  • tocilizumab
  • fluticasone furoate
  • tofacitinib
  • fluticasone furoate/vilanterol trifenatate
  • tolcapone
  • fluticasone propionate
  • tolmetin sodium
  • fluticasone propionate/salmeterol
  • topotecan
  • fluticasone propionate/salmeterol xinafoate
  • toremifene citrate
  • fluvastatin
  • torsemide
  • formoterol fumarate
  • trametinib dimethyl sulfoxide
  • formoterol fumarate/mometasone furoate
  • trandolapril
  • fosamprenavir calcium
  • tranexamic acid
  • fosinopril sodium
  • trastuzumab
  • fulvestrant
  • treprostinil
  • furosemide
  • treprostinil diolamine
  • gefitinib
  • tretinoin
  • gemcitabine
  • triamcinolone
  • gemfibrozil
  • triamcinolone acetonide
  • gemtuzumab ozogamicin
  • triamterene
  • gentamicin sulfate/prednisolone acetate
  • trientine
  • glatiramer acetate
  • trifluridine and tipiracil
  • glecaprevir/pibrentasvir
  • trihexyphenidyl
  • glutamine
  • triptorelin
  • golimumab
  • ustekinumab
  • goserelin acetate
  • valrubicin
  • gramicidin/neomycin sulfate/polymyxin b sulfate
  • valsartan
  • granisetron
  • valsartan/hydrochlorothiazide
  • guselkumab
  • vandetanib
  • halcinonide
  • vedolizumab
  • halobetasol propionate
  • velaglucerase alfa
  • haloperidol
  • vemurafenib
  • histrelin
  • venetoclax
  • homatropine
  • verapamil
  • human amniotic membrane
  • verteporfin
  • human skin allograft
  • vigabatrin
  • hydralazine
  • vinblastine
  • hydrochlorothiazide
  • vincristine
  • hydrochlorothiazide/lisinopril
  • vincristine sulfate
  • hydrochlorothiazide/losartan
  • vinorelbine tartrate
  • hydrochlorothiazide/olmesartan medoxomil
  • vismodegib
  • hydrochlorothiazide/quinapril
  • vitamin A supplement
  • hydrochlorothiazide/triamterene
  • vitamin D2
  • hydrocortisone
  • vitamin/mineral supplement
  • hydrocortisone acetate
  • von willebrand factor/coagulation factor Vlll complex (human)
  • hydrocortisone acetate/urea
  • voretigene neparvovec-rzyl
  • hydrocortisone butyrate
  • vorinostat
  • hydrocortisone probutate
  • warfarin
  • hydrocortisone sodium succinate
  • warfarin sodium
  • hydrocortisone valerate
  • wound dressing
  • hydrocortisone/neomycin/polymyxin b sulfate
  • wound matrix
  • hydrocortizone
  • zafirlukast
  • hydroxychloroquine
  • zidovudine
  • hydroxyurea
  • zileuton
  • hydroxyzine
  • zinc acetate
  • ibalizumab-uiyk
  • ziv-aflibercept
  • ibandronate sodium
  • zoledronic acid
  • ibritumomab tiuxetan
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated July 10, 2018